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Advance Directives (1.2.15)

Advance Directives (1.2.15) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.15


UW HEALTH CLINICAL POLICY 1
Policy Title: Advance Directives
Policy Number: 1.2.15
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 20, 2017

I. PURPOSE

A. To establish procedures to ensure that UW Health meets the requirements of the Patient Self-Determination
Act, and to ensure proper dissemination of information regarding Advance Directives, specifically the Power
of Attorney for Health Care (Wis. Stat. Ch. 155) and the Declaration to Physicians (hereafter referred to as
"Living Will") (Wis. Stat. § 154.02–154.15).
B. To establish a procedure for enabling a competent adult patient to execute a Power of Attorney for Health
Care or Living Will.
C. To provide guidelines for implementing Power of Attorney for Health Care Documents and Living Wills at
UW Health.
D. To define the obligations of health care professionals with regard to advance directives both formal and
informal.
II. DEFINITIONS
A. An "Advance Directive" is a voluntary expression of a competent patient's wishes for future health
care. Advance Directives become relevant when a previously competent patient is no longer capable of
making health care decisions. In Wisconsin, Advance Directives include:
i. Power of Attorney for Health Care
ii. Living Will
iii. Out-of-hospital Do Not Resuscitate (DNR) or “no CPR” orders, which are not addressed in this
policy. Refer to UW Health clinical policy, #1.2.13, Do Not Resuscitate.
B. An “Expression of Wishes” is a verbal or written expression of a patient’s goals and values and how those
influence the patient’s wishes for future health care decisions. Expressions of Wishes are made at a time
that the patient was competent but are not documented in any Advance Directive as outlined above. While
an Expression of Wishes is not a legal Advance Directive, it may offer guidance for a surrogate in making
health care decisions when the patient lacks Capacity. An Expression of Wishes may include verbal or
written evidence of a patient's expressed wishes to family or friends, chart notes of conversations between
health care providers and the patient, or letters or other documentation expressing a patient's wishes. In
some cases, an Advance Directive that is not properly completed (e.g., because it was not properly
witnessed) may still constitute an Expression of Wishes.
C. "Health Care Agent" or “Agent” means an individual designated by a principal through a power of attorney
for health care to make health care decisions on his or her behalf when the principal has Incapacity.
D. "Incapacity" means the inability to receive and evaluate information effectively or to communicate decisions
to such an extent that the individual lacks the capacity to manage his or her health care decisions. Mere old
age, eccentricity, or physical disability, singly or together, is insufficient to make a finding of Incapacity.
E. "Capacity" means the ability to receive and evaluate information effectively or to communicate decisions to
such an extent that the individual is able to manage his or her health care decisions.
F. "Principal" means an individual (the patient) who executes a power of attorney for health care.
G. "Power of Attorney for Health Care" means the designation by a Principal of another individual as his or her
Health Care Agent for the purpose of making health care decisions on his or her behalf if the individual
cannot, due to Incapacity.
H. In Wisconsin State Law, a "Living Will" is a specific kind of advance directive applicable only under narrow
circumstances. The law defines a “Living Will” as a written declaration authorizing the withholding or
withdrawing of life-sustaining procedures and/or tube feedings for patients in a terminal condition or in a
persistent vegetative state. A Living Will may also be called a Declaration to Physicians.
i. In the context of a Living Will in the State of Wisconsin, a finding of "Persistent Vegetative State"
requires a determination based on reasonable medical judgment that the patient has suffered
complete and irreversible loss of all functions of the cerebral cortex, resulting in a complete,
chronic, and irreversible cessation of all cognitive functioning and consciousness and a complete
lack of behavioral responses that indicate cognitive functioning, although autonomic functions
continue.
ii. In the context of a Living Will in the State of Wisconsin, "Terminal Condition" means, as determined
by two physicians who have examined the patient, an incurable condition caused by injury or illness



UW HEALTH CLINICAL POLICY 2
Policy Title: Advance Directives
Policy Number: 1.2.15

that reasonable medical judgment finds would cause death imminently, so that the application of
life-sustaining procedures serves only to postpone the moment of death.
III. POLICY ELEMENTS

UW Health is committed to providing health care in an environment which preserves the autonomy of
patients in health care decision making. In addition to Do Not Resuscitate Orders (addressed by UW Health
Clinical Policy #1.2.13, Wisconsin law recognizes two other forms of Advance Directives: the Power of
Attorney for Health Care and Living Will. In addition, Expressions of Wishes should also be used to guide
health care decisions by surrogates as outlined in this policy.

Staff caring for patients are encouraged to engage patients while alert and possessing Capacity in a
discussion of their wishes, goals, and values as these relate to current and future decisions about health
care, particularly regarding life-sustaining treatments. Additionally, staff should facilitate patients' requests to
review and revise existing advance directives.

UW Health will make provisions for implementation of patients' Advance Directives in the hospital or
outpatient setting and will provide procedures whereby a patient's clearly communicated and reliable
Expressions of Wishes regarding termination of life-sustaining procedures can be implemented.

No patient will be denied health care on the grounds that the patient has or has not executed an Advance
Directive.

IV. PROCEDURE

A. Receiving Power of Attorney (POA) for Health Care or Living Will documents.
i. Inpatient: On the inpatient units, staff that receives advance directive documents of current
inpatients will have a social worker validate the documents and then make a copy to place it in the
patient's chart on the inpatient unit until available via the electronic health record (EHR). Staff shall
send an additional copy to the Coordinated Care Office, tube 661, for final inpatient review, and
then sent to HIM for processing into the EHR. The original POA should be returned to the patient.
ii. Outpatient: In the outpatient setting, staff that receives advance directive documents will
immediately route a copy to HIM for approval & scanning/indexing into the EHR. Refer to Section
VI, Health Information Management (HIM).
B. Advising Inpatients about Advance Directives.
i. During initial nursing assessment, the RN will inquire whether the patient has executed, prior to
coming to UW Health, a health care power of attorney or other Advance Directive and will
document it in the EHR. When an Advance Directive has been previously executed, the RN will ask
the patient if UW Health has a copy on file, and if the document reflects the patient's current
wishes. If the patient indicates that UW Health does not have a copy of their document, the RN will
request a copy and document the request. If the patient does not have a POA already developed,
the RN will then offer each adult patient the opportunity to complete the Wisconsin Power of
Attorney for Health Care Document. If yes, the RN will send an electronic consult request to Social
Work to follow up with the patient.
C. Advising Outpatients about Advance Directives.
i. General information about Advance Directives will be available in all adult clinic reception/waiting
areas. If a patient provides an advance directive, it will immediately be sent to HIM (refer to Section
VI) to be validated & scanned into the EHR.
ii. Information about Advance Directives will be provided upon patient request. Patients wanting more
information or help completing an Advance Directive will be referred to the Patient Resources
Department (608-821-4819) or to the Clinic Social Worker if that clinic has a social worker
assigned.
iii. Patients can be advised that forms can be obtained online at uwhealth.org.
iv. Outpatients with a potential to be admitted, such as those scheduled for outpatient surgery or
procedures requiring conscious sedation, will be asked to provide current Advance Directives or will
be offered information to develop an Advance Directive if that patient so chooses.
v. Individual clinics that provide care to patients with chronic illness (e.g., renal failure or HIV) may
have more clinic-specific standards of care for obtaining Advance Directives.



UW HEALTH CLINICAL POLICY 3
Policy Title: Advance Directives
Policy Number: 1.2.15

D. POA for Health Care Guidelines.
i. Inpatients: The admitting nurse will determine whether the patient has already executed a POA.
The patient should be given the opportunity to update or execute a new version of the document
via a Social Work Consult.
ii. Outpatients: Patients may present their clinic or Patient Resources with a copy of their POA for
inclusion in their EHR.
iii. Documents will be available from Admissions, inpatient nurses, social workers, Learning Center,
Patient Resources, and adult clinic reception areas.
iv. The statutory limitations on the health care agent's authority are listed in the statutory POA form
and in Wisconsin Statutes chapter 155.
v. Inpatients having questions about completing a POA should be referred to Social
Work. Outpatients should be referred to Patient Resources.
E. Signing, witnessing, and filing the Power of Attorney for Health Care.
i. The document must be completed and signed voluntarily by the competent patient and witnessed
by two adults. Any adult, other than the following, may serve as a witness:
a. Related to the Principal by blood, marriage, or adoption.
b. Having knowledge that he or she is entitled to or has claim on any portion of the
Principal's estate.
c. Directly financially responsible for the Principal's health care.
d. Who is a UW Health employee (except social workers and chaplains).
e. Who is the Principal's Health Care Agent.
ii. Any individual may be designated a Health Care Agent by the patient, except the following
categories (unless they are a relative of the patient):
a. Health care providers of the patient.
b. Employees of health care providers of the patient.
c. Employees of health care facilities in which the Principal is a patient or resides.
d. Spouses of any of the above providers or employees.
iii. The Advance Directive will be scanned into Health Link (refer to section VI, Health Information
Management).
iv. Patients wishing to execute an advance directive during evenings and weekends when chaplains,
social workers and volunteers are often unavailable to serve as witnesses should be given an
opportunity to make an Expression of Wishes. (See Section V.)
F. Revocation of the POA for Health Care.
i. A patient's POA is revoked by any of the following:
a. Canceling, defacing, obliterating, burning, tearing or otherwise destroying the instrument
or directing another in the presence of the Principal to so destroy the POA for health care
instrument.
b. The Principal executing a written statement signed and dated expressing intent to revoke
the POA.
c. The Principal verbally expressing intent to revoke in the presence of 2 witnesses.
d. The Principal subsequently executing a new power of attorney for health care instrument.
e. Divorce by the patient if the patient's spouse was the patient's designated health care
agent.
f. By court order in a guardianship or other court proceeding
ii. A Principal may revoke a POA as outlined in Section V.F.i. even after it has been activated.
iii.
iv. Any knowledge of revocation of a patient's POA obtained by UW Health personnel shall be
communicated to a nurse or physician of the patient who shall record in the patient's EHR the time,
date, and place of revocation and time, date, and place of notification of revocation to the patient's
health care provider. All documentation of the revocation of a patient's POA must be forwarded to
HIM (refer to Section VI).
If there is a new POA replacing the revoked one, that will be validated and then scanned/indexed
into the EHR. HIM will annotate the following in the middle of page one of the old Advance
Directive, "REVOKED mm/dd/yyyy” If there is no replacement document and just a letter revoking
the advance directive from patient, that will be scanned into the original document as page 1.
G. Guidelines for activating the patient's POA.



UW HEALTH CLINICAL POLICY 4
Policy Title: Advance Directives
Policy Number: 1.2.15

i. The power of attorney is activated when the patient is determined to be incapacitated by two
licensed physicians or a licensed physician and a licensed psychologist after personal examination
of the patient. The physicians or psychologist determining Incapacity cannot be related to the
patient or have knowledge that he or she has a claim on any portion of the patient's estate.
ii. A patient's POA cannot be activated without obtaining a copy of the document. If a copy of the POA
is not available, the procedures for implementing an Expression of Wishes must be followed (refer
to Section V. Expressions of Wishes).
iii. A finding of Incapacity must be documented in the patient's EHR by two licensed physicians or a
licensed physician and a psychologist making this determination. Physicians should complete the
form "UW Health Physician Certification of Incapacity/Regained Capacity", and forward a copy
immediately to HIM for approval & scanning/indexing into the EHR (refer to Section VI).
iv. For patients who intermittently have Capacity (e.g., Alzheimer's disease, delirium, or sedated as
part of their medical care) the physicians should document such a finding. In these cases both the
agent and the patient should be consulted about health care decisions.
H. Use of the POA for health care.
i. There are statutory limitations on the power of the health care agent, which are further explained in
the statutory form. The agent may not consent to:
a. Admission of the Principal on an inpatient basis to mental health facilities.
b. Admission of the Principal to community-based residential facilities or nursing homes
except for short periods of time, not to exceed three months, unless the POA so
authorizes and the patient is not mentally ill or developmentally disabled when admitted
(since a health care agent doesn't have the authority to admit mentally ill or
developmentally disabled patients to such facilities, placement of these individuals will
require a court-appointed guardian).
c. Psychosurgery, electroconvulsive therapy (ECT), or other drastic mental health treatment
procedures or experimental mental health research. When considering ECT for patients
without Capacity, see UW Health Clinical Policy #2.3.1, Electroconvulsive Therapy.
d. Withholding or withdrawal of orally ingested nutrition or hydration unless the physician
determines that such nutrition or hydration is medically contraindicated.
e. Health care decisions when the patient has regained Capacity to make his/her own
decisions.
ii. The health care agent must act in good faith consistent with the desires of the patient as expressed
in the POA or as specifically expressed by the patient to the agent at any time. If there has been no
directive by the patient, the health care agent shall in good faith act in the best interests of the
patient.
iii. The health care agent may not make decisions for an incapacitated pregnant patient unless
authorized by the POA.
iv. A health care agent may review and receive copies of the principal's medical and mental health
records and consent to disclosure of information contained in those records.
v. A health care agent may execute, on the principal's behalf, documents such as:
a. "Consent for Treatment"
b. "Refusal of Treatment"
c. "Leaving Hospital Against Medical Advice"
d. "Refusal to Permit Blood Transfusions"
e. A form waiving or releasing hospital or physician liability
vi. A health care agent may make an anatomical gift of all or a part of the patient's body after the
patient's death, unless the patient made an un-revoked refusal to make that anatomical gift.
vii. The patient's physician may consult the UW Health Ethics Committee on any issue related to the
implementation of a patient's Advance Directive. Such consultations are particularly appropriate
when there are problems related to withdrawal or withholding of treatment, or the implementation of
an Expression of Wishes.
viii. Questions concerning the validity or interpretation of a patient's POA should be raised with the UW
Health Attorney On-Call or the UW-Madison Office of Legal Affairs Attorney On-Call.
I. Guidelines for deactivating the patient's POA.
i. A finding of regained Capacity must be documented in the patient's EHR by the licensed physician
or psychologist making the determination.



UW HEALTH CLINICAL POLICY 5
Policy Title: Advance Directives
Policy Number: 1.2.15

ii. The physician or psychologist making the determination should complete the form UW Health
Physician Certification of Incapacity/Regained Capacity, and forward immediately to HIM 2427 for
approval & scanning/indexing into the EHR (refer to Section VI).
J. Living Will Guidelines.
i. Inpatients: The admitting nurse will determine whether the patient has already executed a Living
Will.
ii. Outpatients: Patients may present their clinic or Patient Resources with a copy of their Living Will
for inclusion in their electronic health record.
iii. If the patient indicates that he/she has a Living Will, a copy of that directive should be obtained and
forwarded immediately to HIM for approval & scanning/indexing into the EHR (refer to Section VI).
iv. Patients wishing to execute a Living Will may obtain a form from the Department of Patient
Resources, Social Work, or online at uwhealth.org.
v. The document must be completed and signed voluntarily by the patient and witnessed by two
adults. The following may not act as witnesses - any individual:
a. Related to the patient by blood, marriage, or adoption.
b. Having knowledge that he or she is entitled to or has claim on any portion of the patient's
estate.
c. Directly financially responsible for the patients’ health care.
d. Any UW Health employee (except for social workers and chaplains).
vi. An acknowledgement letter is sent back to the patient after it is scanned into the electronic health
record.
vii. A Living Will is revoked by the patient doing any of the following:
a. Signing and dating a written statement revoking the Living Will.
b. Defacing, canceling, obliterating, burning, tearing, or otherwise destroying the Living Will
or a copy thereof (or asking another person to do the same in his or her presence).
c. Verbally expressing intent to revoke the Living Will and notifying the attending physician of
this intent.
d. Executing a subsequent Living Will.
viii. Any knowledge of revocation of a patient's Living Will obtained by UW Health personnel shall be
communicated to a nurse or physician of the patient who shall record in the patient's EHR the time,
date, and place that the Living Will was revoked and the time, date, and place that s/he was notified
of the revocation if different. All documentation of the revocation of the patient's Living Will must be
immediately forwarded to HIM (refer to Section VI).
If there is a new Living Will replacing the revoked one, that will be validated and then
scanned/indexed into the EHR. HIM will annotate the following in the middle of page one of the old
advance directive "REVOKED mm/dd/yyyy”. If there is no replacement document and just a letter
revoking the advance directive from the patient, then that will be scanned/indexed into the original
document as page 1.
ix. A patient's authorization in a Living Will document will not go into effect if a patient is pregnant and
the physician is aware of the pregnancy.
x. A Living Will cannot be used to authorize withholding or withdrawal of any medication, procedure or
feeding tube if to do so would cause the patient pain or reduce comfort, and the pain or discomfort
cannot be alleviated through pain relief measures. The Living Will also cannot be used to authorize
the withholding or withdrawal of nutrition or hydration that is administered through means other
than a feeding tube unless, in the physician's opinion, such administration is medically
contraindicated. The express desires of a patient who possesses decisional capacity supersede the
Living Will at all times.
V. EXPRESSIONS OF WISHES

A. Conversations between the patient and health care professionals about patient's Expression of Wishes must
be noted in the EHR.
B. An Expression of Wishes should be evaluated with regard to the circumstances in which they were
expressed and in light of other evidence of the patient's wishes. Conflicts may arise between a patient's
Expression of Wishes and Advance Directives. If the patient's wishes are unclear or there is doubt about the
circumstances in which they were expressed, life-sustaining treatment should continue until such doubts are
resolved, and consideration should be given to consulting the Hospital Ethics Committee. If the patient



UW HEALTH CLINICAL POLICY 6
Policy Title: Advance Directives
Policy Number: 1.2.15

becomes incapacitated, the attending physician or designee should discuss the patient's wishes, goals, and
values with his or her family members or involved significant others.
C. For questions pertaining to Expression of Wishes on termination of life-sustaining treatment issues, refer to
UWHC policy #8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment.
VI. HEALTH INFORMATION MANAGEMENT
A. Health Information Management (HIM) will receive all Advance Directives and acknowledge receipt of the
POA or Living Will in writing (Wisconsin law requires written acknowledgement of the POA).
B. All formal advance directives received in HIM are scanned into the EHR. Electronic scanning began
February 1st, 2001. Paper documents located by UW Health personnel that have not yet been scanned into
the EHR should be sent to: HIM Advance Directives, 8501 Excelsior Drive, MC 2427 for approval &
scanning/indexing into the EHR: Advance Directives can be routed to HIM in several ways:
i. Via Inter-d mail – Attn: HIM Advance Directives, 8501 Excelsior Drive MC 2427
ii. Via Fax – Address to HIM Advance Directives and fax to 608-203-1039
iii. Via E - Submission – Most clinics have scanners that allow staff to scan documents to HIM into a
work queue for approval & importing into the EHR
C. For those patients admitted to the hospital.
i. The Health Unit Coordinator will check for advance directives in the electronic chart.
ii. If one exists, they will print it out and file it in the inpatient chart under the "Advance Directive" tab
and place a sticker on the cover of the chart.
VII. SPECIAL CONSIDERATIONS FOR CERTAIN PATIENT POPULATIONS
A. Persons under age 18 are not eligible to complete a Living Will or Power of Attorney for Health Care.
Although they may legally lack Capacity, mature minors' wishes should be taken into consideration. Where
there appears to be disagreement between a mature minor and a parent, the health care providers may wish
to consult the Hospital Ethics Committee. In cases of health care decision-making for married emancipated
minors, the parents and spouse of such minor should be consulted.
B. Prisoners have the same rights to advance directives as other competent adults.
VIII. OTHER CONSIDERATIONS
A. Operational or legal questions about Advance Directives and Expressions of Wishes should be referred to
the Coordinated Care Office, Social Work Manager or Patient Resources.
B. Questions pertaining to the Capacity of patients wanting to complete an Advance Directive should be
referred to the attending physician.
C. The patient's physician or other health care provider may consult the Hospital Ethics Committee on any
issue related to the implementation of Advance Directives. To contact the Ethics Committee consultant on
call, refer to the monthly on call schedule, available via Paging.
D. A valid document granting a Health Care Agent authority to make health care decisions for a Principal that
was executed in another state or jurisdiction in compliance with that state’s or jurisdiction’s law is valid and
enforceable in Wisconsin to the extent the document authorizes the Health Care Agent to make decisions
for the Principal that could be made by a Health Care Agent under Wisconsin law. Patients who reside in
other states may execute a Wisconsin POA or Living Will. Out of state patients with questions should be
referred to Social Work.

IX. FORMS

-Power of Attorney (POA) for Health Care form prescribed by Wis. Stat.§ 155.30., F-00085
-Living Will form prescribed by Wis. Stat.§ 154.03., F-00060
-UW Health Physician Certification of Incapacity/Regained Capacity form, 301396-DT

X. COORDINATION

Author: Manager, Social Work and Spiritual Care Services and Director, Patient Resources



UW HEALTH CLINICAL POLICY 7
Policy Title: Advance Directives
Policy Number: 1.2.15

Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Advanced Care Planning Coordinator; Health Information Management; UW Health Legal
Department
Approval committees: Hospital Ethics Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: August 21, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

XI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

XII. REFERENCES

UW Health Clinical Policy #1.2.13, Do Not Resuscitate
UWHC policy # 8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment
UW Health Clinical Policy #2.3.1, Electroconvulsive Therapy (ECT)

XIII. REVIEW DETAILS
Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #4.37, MF policy #114.001, Advance Directives